Abstract
Background
Meta-analyses of youth mass trauma intervention studies have focused primarily on posttraumatic stress even though depression and anxiety are common maladaptive outcomes that require intervention.
Objective
This meta-analysis examined youth mass trauma intervention effects on depression and anxiety relative to natural recovery and characteristics of the event, context, population, intervention, and intervention delivery that may have moderated these effects.
Method
A literature search identified 21 studies investigating the effectiveness of 24 randomized controlled trials with inactive controls (21 trials examined depression and 8 examined anxiety; 5 examined both). Intervention effects were computed as Hedge’s g estimates and combined using random effects models. Moderator analysis computed intervention effect sizes across selected covariates.
Results
The summary intervention effect was not significant for either depression or anxiety. There were statistically significant effects for depression with interventions delivered following a natural disaster (g = 0.40; p = 0.0192) or in a high income country (g = 0.30; p = 0.0253) and with non-trauma-focused interventions (g = 0.29; p = 0.0155) and those delivered in more than eight sessions (g = 0.23; p = 0.0416). The effect for anxiety symptoms was significant only with non-trauma-focused interventions (g = 0.83; p = 0.0428).
Conclusions
Given the prevalence of depression and anxiety post event, greater attention is warranted to develop and maximize the benefit of interventions for these outcomes. The findings suggest that trauma-focused interventions may need to be augmented with specific components directed at depression and/or anxiety.
Similar content being viewed by others
References
Alisic, E., Zalta, A. K., van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., et al. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. The British Journal of Psychiatry, 204, 335–340. https://doi.org/10.1192/bjp.bp.113.131227.
Barron, I., Abdallah, G., & Heltne, U. (2016). Randomized control trial of Teaching Recovery Techniques in rural occupied Palestine: Effect on adolescent dissociation. Journal of Aggression, Maltreatment & Trauma, 25(9), 955–973. https://doi.org/10.1080/10926771.2016.1231149.
Berger, R., & Gelkopf, M. (2009). School-based intervention for the treatment of Tsunami-related distress in children: A quasi-randomized controlled trial. Psychotherapy and Psychosomatics, 78(6), 364–371. https://doi.org/10.1159/000235976.
Berger, R., Gelkopf, M., & Heineberg, Y. (2012). A teacher-delivered intervention for adolescents exposed to ongoing and intense traumatic war-related stress: A quasi-randomized controlled study. Journal of Adolescent Health, 51(5), 453–461. https://doi.org/10.1016/j.jadohealth.2012.02.011.
Berger, R., Pat-Horenczyk, R., & Gelkopf, M. (2007). School-based intervention for prevention and treatment of elementary-students’ terror-related distress in Israel: A quasi-randomized controlled trial. Journal of Traumatic Stress, 20(4), 541–551. https://doi.org/10.1002/jts.20225.
Betancourt, T. S., Meyers-Ohki, S. E., Charrow, A. P., & Tol, W. A. (2013). Interventions for children affected by war: An ecological perspective on psychosocial support and mental health care. Harvard Review of Psychiatry, 21(2), 70–91. https://doi.org/10.1097/hrp.0b013e318283bf8f.
Bolton, P., Bass, J., Betancourt, T., Speelman, L., Onyango, G., Clougherty, K. F., et al. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in Northern Uganda. A randomized controlled trial. JAMA, 298(5), 519–527. https://doi.org/10.1001/jama.298.5.519.
Bolton, D., O’Ryan, D., Udwin, O., Boyle, S., & Yule, W. (2000). The long-term psychological effects of a disaster experienced in adolescence: II. General Psychopathology. Journal of Child Psychology and Psychiatry, 41(4), 513–523. https://doi.org/10.1111/1469-7610.00636.
Bonanno, G. A., Brewin, C. R., Kaniasty, K., & La Greca, A. M. (2010). Weighing the costs of disaster: Consequences, risks, and resilience in individuals, families, and communities. Psychological Science in the Public Interest, 11(1), 1–49. https://doi.org/10.1177/1529100610387086.
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Introduction to meta-analysis. Chichester, West Sussex: Wiley.
Brown, F. L., de Graaff, A. M., Annan, J., & Betancourt, T. S. (2017a). Annual Research Review: Breaking cycles of violence—A systematic review and common practice elements analysis of psychosocial interventions for children and youth affected by armed conflict. Journal of Child Psychology and Psychiatry, 58(4), 507–524. https://doi.org/10.1111/jcpp.12671.
Brown, E. J., McQuaid, J., Farina, L., Ali, R., & Winnick-Gelles, A. (2006). Matching interventions to children’s mental health needs: Feasibility and acceptability of a pilot school-based trauma intervention program. Education and Treatment of Children, 29(2), 257–286.
Brown, R. C., Witt, A., Fegert, J. M., Keller, F., Rassenhofer, M., & Plener, P. L. (2017b). Psychosocial interventions for children and adolescents after manmade and natural disasters: A meta-analysis and systematic review. Psychological Medicine, 47(11), 1893–1905. https://doi.org/10.1017/S0033291717000496.
Cary, C. E., & McMillen, J. C. (2012). The data behind the dissemination: A systematic review of trauma-focused cognitive behavioral therapy for use with children and youth. Children and Youth Services Review, 34, 748–757. https://doi.org/10.1016/j.childyouth.2012.01.003.
Chemtob, C. M., Nakashima, J., & Carlson, J. G. (2002). Brief treatment for elementary school children with disaster related posttraumatic stress disorder: A field study. Journal of Clinical Psychology, 58(1), 99–112. https://doi.org/10.1002/jclp.1131.
Chen, Y., Shen, W. W., Gao, K., Lam, C. S., Chang, W. C., & Deng, H. (2014). Effectiveness RCT of a CBT intervention for youths who lost parents in the Sichuan, China, earthquake. Psychiatric Services, 65(2), 259–262. https://doi.org/10.1176/appi.ps.201200470.
Cohen, J. A., & and the Workgroup on Quality Issues. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 49(4), 414–430. https://doi.org/10.1016/j.jaac.2009.12.020.
Day, R. C., & Sadek, S. N. (1982). The effect of Benson’s Relaxation Response on the anxiety levels of Lebanese children under stress. Journal of Experimental Child Psychology, 34, 350–356. https://doi.org/10.1016/0022-0965(82)90052-2.
Del Re, A. C. (2013). compute.es: Compute effect sizes. [R package version 0.2-2]. Retrieved from http://cran.r-project.org/web/packages/compute.es. Accessed 14 Jan 2019.
Duval, S., & Tweedie, R. (2000). A nonparametric “Trim and Fill” method of accounting for publication bias in meta-analysis. Journal of the American Statistical Association, 95, 89–98.
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634. https://doi.org/10.1136/bmj.315.7109.629.
Ertl, V., Pfeiffer, A., Schauer, E., Elbert, T., & Neuner, F. (2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda. A randomized control trial. JAMA, 306(5), 503–512. https://doi.org/10.1001/jama.2011.1060.
Field, T., Seligman, S., Scafidi, F., & Schanberg, S. (1996). Alleviating posttraumatic stress in children following Hurricane Andrew. Journal of Applied Developmental Psychology, 17, 37–50. https://doi.org/10.1016/s0193-3973(96)90004-0.
Fu, C., & Underwood, C. (2015). A meta-review of school-based disaster interventions for child and adolescent survivors. Journal of Child and Adolescent Mental Health, 27(3), 161–171. https://doi.org/10.2989/17280583.2015.1117978.
Furr, J. M., Comer, J. S., Edmunds, J. M., & Kendall, P. C. (2010). Disasters and youth: A meta-analytic examination of posttraumatic stress. Journal of Consulting and Clinical Psychology, 78(6), 765–780. https://doi.org/10.1037/a0021482.
Gelkopf, M., & Berger, R. (2009). A school-based, teacher-mediated prevention program (ERASE-stress) for reducing terror-related traumatic reactions in Israeli youth: A quasi-randomized controlled trial. Journal of Child Psychology and Psychiatry, 50(8), 962–971. https://doi.org/10.1111/j.1469-7610.2008.02021.x.
Hansen, N. B., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9(3), 329–343.
Hedges, L. V. (1981). Distribution theory for Glass’s estimator of effect size and related estimators. Journal of Educational Statistics, 6(2), 107–128. https://doi.org/10.3102/10769986006002107.
Higgins, J. P. T., Savović, J., Page, M. J., & Sterne, J. A. C. (Eds.) (2016). Revised Cochrane risk of bias tool for randomized trials (RoB 2.0). Retrieved from: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool. Accessed 6 July 2017.
Integrated Regional Information Networks (IRIN). (2005, June). Disaster reduction and the human cost of disaster. IRIN Web Special. Retrieved from https://reliefweb.int/report/world/disaster-reduction-and-human-cost-disaster-irin-web-special. Accessed 2 Jan 2019.
Jordans, M. J. D., Komproe, I. H., Tol, W. A., Kohrt, B. A., Luitel, N. P., Macy, R. D., et al. (2010). Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: A cluster randomized controlled trial. Journal of Child Psychology and Psychiatry, 51(7), 818–826. https://doi.org/10.1111/j.1469-7610.2010.02209.x.
Karam, E. G., Fayyad, J., Karam, A. N., Melhem, N., Mneimneh, Z., Dimassi, H., et al. (2014). Outcome of depression and anxiety after war: A prospective epidemiologic study of children and adolescents. Journal of Traumatic Stress, 27, 192–199. https://doi.org/10.1002/jts.21895.
La Greca, A. M., & Silverman, W. K. (2011). Interventions for youth following disasters and acts of terrorism. In P. C. Kendall (Ed.), Child and adolescent therapy. Cognitive-behavioral procedures (4th ed., pp. 324–344). New York, NY: Guilford Press.
La Greca, A. M., Silverman, W. K., & Wasserstein, S. B. (1998). Children’s predisaster functioning as a predictor of posttraumatic stress following Hurricane Andrew. Journal of Consulting and Clinical Psychology, 66(6), 883–892.
Lai, B. S., Auslander, B. A., Fitzpatrick, S. L., & Podkowirow, V. (2014). Disasters and depressive symptoms in children: A review. Child & Youth Care Forum, 43(4), 489–504. https://doi.org/10.1007/s10566-014-9249-y.
Lai, B. S., La Greca, A. M., Auslander, B. A., & Short, M. B. (2013). Children’s symptoms of posttraumatic stress and depression after a natural disaster: Comorbidity and risk factors. Journal of Affective Disorders, 146, 71–78.
Magruder, K. M., McLaughlin, K. A., & Borbon, D. L. E. (2017). Trauma is a public health issue. European Journal of Psychotraumatology, 8(1), 1375338. https://doi.org/10.1080/20008198.2017.1375338.
Miller, K. E., Kulkarni, M., & Kushner, H. (2006). Beyond trauma-focused psychiatric epidemiology: Bridging research and practice with war-affected populations. American Journal of Orthopsychiatry, 76(4), 409–422. https://doi.org/10.1037/0002-9432.76.4.409.
Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Social Science and Medicine, 70(1), 7–16. https://doi.org/10.1016/j.socscimed.2009.09.029.
Morina, N., Koerssen, R., & Pollet, T. V. (2016). Interventions for children and adolescents with posttraumatic stress disorder: A meta-analysis of comparative outcome studies. Clinical Psychology Review, 47, 41–54. https://doi.org/10.1016/j.cpr.2016.05.006.
Morina, N., Malek, M., Nickerson, A., & Bryant, R. A. (2017). Psychological interventions for post-traumatic stress disorder and depression in young survivors of mass violence in low- and middle-income countries: Meta-analysis. The British Journal of Psychiatry, 210, 247–254. https://doi.org/10.1192/bjp.bp.115.180265.
Morris, J., van Ommeren, M., Belfer, M., Saxena, S., & Saraceno, B. (2007). Children and the Sphere standard on mental and social aspects of health. Disasters, 31(1), 71–90. https://doi.org/10.1111/j.1467-7717.2007.00341.x.
Moss, W. J., Ramakrishnan, M., Storms, D., Siegle, A. H., Weiss, W. M., Lejnev, I., et al. (2006). Child health in complex emergencies. Bulletin of the World Health Organization, 84(1), 58–64.
Newman, E., Pfefferbaum, B., Kirlic, N., Tett, R., Nelson, S., & Liles, B. (2014). Meta-analytic review of psychological interventions for children survivors of natural and man-made disasters. Current Psychiatry Reports, 16(462), 1–10. https://doi.org/10.1007/s11920-014-0462-z.
Norris, F. H., Friedman, M. J., & Watson, P. J. (2002a). 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry, 65(3), 240–260.
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002b). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981–2001. Psychiatry, 65(3), 207–239.
O’Connor, D., Green, S., & Higgins, J. P. T. (2008). Defining the review question and developing criteria for including studies. In J. P. T. Higgins & S. Green (Eds.), Cochrane handbook for systematic reviews of interventions: Cochrane book series (pp. 81–94). Chichester, UK: John Wiley & Sons. https://doi.org/10.1002/9780470712184.ch5.
Ooi, C. S., Rooney, R. M., Roberts, C., Kane, R. T., Wright, B., & Chatzisarantis, N. (2016). The efficacy of a group cognitive behavioral therapy for war-affected young migrants living in Australia: A cluster randomized controlled trial. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2016.01641.
Pfefferbaum, B., Newman, E., Nelson, S. D., Liles, B. D., Tett, R. P., Varma, V., et al. (2014a). Research methodology used in studies of child disaster mental health interventions for posttraumatic stress. Comprehensive Psychiatry, 55(1), 11–24. https://doi.org/10.1016/j.comppsych.2013.08.014.
Pfefferbaum, B., Shaw, J. A., & the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2013). Practice parameter on disaster preparedness. Journal of the American Academy of Child and Adolescent Psychiatry, 52(11), 1224–1238. https://doi.org/10.1016/j.jaac.2013.08.014.
Pfefferbaum, B., Sweeton, J. L., Newman, E., Varma, V., Noffsinger, M. A., Shaw, J. A., et al. (2014b). Child disaster mental health interventions, part II. Timing of implementation, delivery settings and providers, and therapeutic approaches. Disaster Health, 2(1), 58–67. https://doi.org/10.4161/dish.27535.
Purgato, M., Gross, A. L., Betancourt, T., Bolton, P., Bonetto, C., Gastaldon, C., et al. (2018). Focused psychosocial interventions for children in low-resource humanitarian settings: A systematic review and individual participant data meta-analysis. Lancet Global Health, 6(4), e390–e400. https://doi.org/10.1016/s2214-109x(18)30046-9.
Qouta, S. R., Palosaari, E., Diab, M., & Punamäki, R. (2012). Intervention effectiveness among war-affected children: A cluster randomized controlled trial on improving mental health. Journal of Traumatic Stress, 25(3), 288–298. https://doi.org/10.1002/jts.21707.
Rubonis, A. V., & Bickman, L. (1991). Psychological impairment in the wake of disaster: The disaster-psychopathology relationship. Psychological Bulletin, 109(3), 384–399.
Schmidt, F. L., & Hunter, J. E. (2015). Methods of meta-analysis Correcting error and bias in research findings (3rd ed.). Thousand Oaks, CA: Sage Publications.
Schwarzer, G. (2007). Meta: An R package for meta-analysis. R News, 7(3), 40–45.
Shaffer, J. A., DeGeest, D., & Li, A. (2016). Tackling the problem of construct proliferation: A guide to assessing the discriminant validity of conceptually related constructs. Organizational Research Methods, 19(1), 80–110. https://doi.org/10.1177/1094428115598239.
Shen, Y. J. (2002). Short-term group play therapy with Chinese earthquake victims: Effects on anxiety, depression, and adjustment. International Journal of Play Therapy, 11(1), 43–63. https://doi.org/10.1037/h0088856.
Slone, M., & Shoshani, A. (2008). Efficacy of a school-based primary prevention program for coping with exposure to political violence. International Journal of Behavioral Development, 32(4), 348–358. https://doi.org/10.1177/0165025408090976.
Slone, M., Shoshani, A., & Lobel, T. (2013). Helping youth immediately following war exposure: A randomized controlled trial of a school-based intervention program. Journal of Primary Prevention, 34(5), 293–307. https://doi.org/10.1007/s10935-013-0314-3.
Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine, 48(10), 1449–1462. https://doi.org/10.1016/s0277-9536(98)00450-x.
Tol, W. A., Barbui, C., Galappatti, A., Silove, D., Betancourt, T. S., Souza, R., et al. (2011). Mental health and psychosocial support in humanitarian settings: Linking practice and research. Lancet, 378(9802), 1581–1591. https://doi.org/10.1016/s0140-6736(11)61094-5.
Tol, W. A., Komproe, I. H., Jordans, M. J. D., Ndayisaba, A., Ntamutumba, P., Sipsma, H., et al. (2014). School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial. BMC Medicine, 12(1), 56. https://doi.org/10.1186/1741-7015-12-56.
Tol, W. A., Komproe, I. H., Jordans, M. J. D., Vallipuram, A., Sipsma, H., Sivayokan, S., et al. (2012). Outcomes and moderators of a preventive school-based mental health intervention for children affected by war in Sri Lanka: A cluster randomized trial. World Psychiatry, 11(2), 114–122. https://doi.org/10.1016/j.wpsyc.2012.05.008.
Tol, W. A., Komproe, I. H., Susanty, D., Jordans, M. J. D., Macy, R. D., & de Jong, J. T. V. M. (2008). School-based mental health intervention for children affected by political violence in Indonesia. A cluster randomized trial. JAMA, 300(6), 655–662. https://doi.org/10.1001/jama.300.6.655.
Unterhitzenberger, J., & Rosner, R. (2014). Lessons from writing sessions: A school-based randomized trial with adolescent orphans in Rwanda. European Journal of Psychotraumatology. https://doi.org/10.3402/ejpt.v5.24917.
Viechtbauer, W. (2010). Conducting meta-analyses in R with the metafor package. Journal of Statistical Software, 36(3), 1–48.
Wang, C., Chan, C. L. W., & Ho, R. T. H. (2013). Prevalence and trajectory of psychopathology among child and adolescent survivors of disasters: A systematic review of epidemiological studies across 1987–2011. Social Psychiatry and Psychiatric Epidemiology, 48(11), 1697–1720. https://doi.org/10.1007/s00127-013-0731-x.
Weems, C. F., Pina, A. A., Costa, N. M., Watts, S. E., Taylor, L. K., & Cannon, M. F. (2007). Predisaster trait anxiety and negative affect predict posttraumatic stress in youths after Hurricane Katrina. Journal of Consulting and Clinical Psychology, 75(1), 154–159. https://doi.org/10.1037/0022-006X.75.1.154.
Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M., Vaughn-Coaxum, R., et al. (2017). What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72(2), 79–117. https://doi.org/10.1037/a0040360.
World Bank Data Help Desk. (n.d.). Historical classification of countries by income. Washington, DC: Author. Retrieved from https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups. Accessed 2 Jan 2019.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
This research was not supported by any grant from public, commercial, or not-for-profit funding agencies. None of the authors of the manuscript discloses any interest which might be interpreted as influencing the research or compromising ethical standards. The findings, conclusions, and opinions in this article are those of the authors and do not represent the official position of The University of Oklahoma Health Sciences Center, The University of Oklahoma, or The University of Tulsa.
Ethical Standards
This article reports an analysis of published literature. No assessment of human participants was conducted. Thus, Institutional Review Board approval and informed consent were not required for this project.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Pfefferbaum, B., Nitiéma, P. & Newman, E. A Meta-analysis of Intervention Effects on Depression and/or Anxiety in Youth Exposed to Political Violence or Natural Disasters. Child Youth Care Forum 48, 449–477 (2019). https://doi.org/10.1007/s10566-019-09494-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10566-019-09494-9